App 17 Application: Maternity / Paternity Leave (Âś355) Name:
______________________________________________________________________
Address:
First
Middle
Last
______________________________________________________________________ Street
City
State
Zip
Best Contact # (______)________-__________ Birthdate: _________ _________ __________ [__] Cell [__] Home [__] Work Month Day Year Email: ______________________________________________________________________ Status: [__] Local Pastor [__] Provisional Member [__] Associate Member [__] Full Deacon [__] Full Elder District: [__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR Charge: ______________________________________________________________________ I hereby request maternity / paternity leave, having been in consultation with my District Superintendent, after speaking with the Pastor Parish Relations Committee of my church / charge and filing a written request with that committee.
[__] [__]
I confirm I have had discussions with my District Superintendent at least ninety (90) days before the date of this requested leave. _________ _________ __________ The anticipated date this leave will begin is
[__]
The anticipated date this leave will end is
Month
Day
Year
Month
Day
Year
_________ _________ __________ (This can be flexible, since there are always circumstances that might change the date. Our goal would be to give the full amount of time you request based upon the date you actually begin)
[__]
I understand that I may take leave for up to one quarter (1/4) of a year (13 weeks), but that compensation will only be provided for the first eight (8) weeks of this leave.
__________________________ _________________________ ___________________ Signature Printed Name Date _____________________________________________________________________________________ Please submit copies of this application to: [__] The Office of the Bishop [__] The Director of Clergy Services via ClergyServices@holston.org [__] Current District Superintendent Office Use: Episcopal Office approved request: BOMEC/BOM approved request:
Month Day Year _________ _________ __________ _________ _________ __________
Updated: 2020-11